*All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document, you certify, under penalty of perjury and subject to the provisions of Wyo. Stat. 6-5-303, and its penalties, you have not knowingly submitted false or misleading information to the Wyoming State Board of Nursing (WSBN) on any application for licensure, certification or temporary permit. WSBN no longer issues paper copies of licenses, certificates, or temporary permits. Verifications are available on-line at License Verification (https://nursing-online.state.wy.us/verifications.aspx). INSTRUCTIONS AND GENERAL INFORMATION (Keep a copy for your records): Thank you for applying to WSBN for Reinstatement. The following instructions are guidelines for completing the application. Contact the Board office at 307.777.7601, with any questions. We will be happy to assist you! APPLICANT MUST: APPLICATION FOR REINSTATEMENT of WYOMING NURSE LICENSURE or CERTIFICATION Complete the application. Type your information into the fillable PDF document and print the application; or print the application and complete it neatly in INK. DO NOT LEAVE ANY BLANKS, if a section is not applicable, indicate NA on the line/section. An application with blank lines will be considered incomplete. Provide all required information. Incomplete applications will not be processed. Applications will be: o Held for one (1) year from the date received; and o Destroyed after one (1) year, requiring submission of a new application and fees. Provide a current e-mail address, mailing address, and phone number to ensure prompt notification. Issuance of your license may be delayed if we do not have current contact information. Provide the following forms of payment: money order, cashier s check, VISA, MasterCard, or Discover. There are NO REFUNDS for incomplete or withdrawn applications. WSBN does not accept cash or personal check. Mail the application and associated documents to the WSBN office. Faxes will not be accepted. CRIMINAL BACKGROUND CHECK by Division of Criminal Investigation (DCI) In accordance with Wyoming Statute 33021-122(c)(xxiv) and 7-19-201, you are required to complete a Criminal Background Check (CBC) before a license or certificate can be issued. Fingerprints are used for the CBC. Obtain fingerprint cards at your local law enforcement agency. Fingerprints must be on two (2) blue FBI cards. Return these with your completed application and fees. Issuance of your permanent license/certificate is dependent upon receipt of CBC results from DCI. PLAN ACCORDINGLY! Procedures for obtaining a change, correction, or updating a FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34. Page 1 of 7
REQUIREMENTS FOR REINSTATEMENT: Chapter 2, Section 12. Reinstatement of Licensure or Certification provides: An APRN, RN, LPN/LVN or CNA whose license or certificate has been revoked, surrendered, suspended, or conditioned may apply for reinstatement.... APPLICANT MUST: (i) (ii) Submit completed application and fees; Submit CBC fingerprint cards and fees; (iii) Submit evidence of meeting competency under Section 13 1 ; (iv) (v) Submit evidence of meeting requirements of the previous Board s order; and Submit evidence demonstrating just cause for reinstatement. Just Cause for reinstatement may include: Professional letters of recommendation; information indicating rehabilitation (i.e., completion of probation, completion of treatment programs; participation in counseling or support groups); evaluation showing fit for duty. Please Remember: WSBN s primary purpose in consideration of any application for reinstatement, especially in light of prior disciplinary action taken against your license or certificate is that you are adequately competent to practice nursing and there are no circumstances otherwise suggesting there is a risk to the public health, safety and welfare. Your cooperation is greatly appreciated! 1 Section 13. Competency for Licensure/Certification Continuing In or Returning To Practice. (b) (c) (d) * * * APRN (i) An APRN shall demonstrate competency by submitting evidence of: (A) Current national certification as an APRN in the recognized role and population focus area; or (B) If recognized APRN in the State prior to July 1, 2005, and has maintained continuous licensure, but not nationally certified, the APRN shall submit evidence of: (I) Completion of sixty (60) or more CEUs related to the APRN s recognized role and population focus area; and (II) Completion of four hundred (400) or more hours practicing as an APRN during the last two years. (ii) An APRN with prescriptive authority shall submit documentation of completion of fifteen (15) hours of coursework in pharmacology and clinical management of drug therapy within the two (2) years prior to license expiration. RN/LPN/LVN. A RN or LPN/LVN shall demonstrate competency by completing one of the following in the past two (2) years (waived during first renewal period if you were licensed by exam): (i) Four hundred (400) hours of employment in the practice of nursing; or (ii) Two hundred (200) hours of employment in the practice of nursing and fifteen (15) hours of education that provides learning activities related to the practice of nursing; or (iii) Thirty (30) hours of education that provides learning activities related to nursing practice; (iv) If the applicant has not practiced nursing during the last five (5) years, applicant shall: (A) Successfully complete a refresher course or the equivalent, accepted by the Board; or (B) Successfully complete a nursing education program that confers a degree beyond the licensee s basic nursing education; or (C) Obtain a certification by a nationally recognized professional accrediting agency in a specialty area of nursing that is accepted by the Board: or (D) Successfully pass NCLEX. CNA. A CNA shall demonstrate competency by completing one of the following in the past two (2) years (waived during the first renewal period if you were licensed by exam): (i) Four hundred (400) hours of employment in the CNA role; or (ii) Two hundred (200) hours of employment in the CNA role and fifteen (15) hours of education that provides learning activities related to nursing practice; or (iii) Thirty (30) hours of education that provides learning activities related to nursing practice. (iv) A CNA who is unable to meet competency shall be required to repeat the training and competency evaluation. Page 2 of 7
FEES (All fees are non-refundable and subject to change) You must include payment with your application; we accept CASHIER S CHECK, MONEY ORDER, VISA, MASTERCARD OR DISCOVER. Name of Applicant (PLEASE PRINT): WSBN CANNOT ACCEPT PERSONAL CHECKS OR CASH. Cost Amount APRN Reinstatement Fee $ 255.00 $ RN Reinstatement Fee $ 135.00 $ LPN Reinstatement Fee $ 120.00 $ CNA Reinstatement Fee $ 60.00 $ CBC / Fingerprint Fee $ 60.00 $ 60.00 Processing fee if paying by VISA, MasterCard or Discover (automatically assessed) $ 5.00 $ 5.00 TOTAL amount due: $ Name, Address, and Phone Number of Individual Paying (PLEASE PRINT): Licensee Paying Third Party Paying Visa MasterCard Discover Card Number and Three Digit Security Code (on back of card): Security Code: - - - Expiration Date: By signing below, I authorize the Board of Nursing to debit my credit card for the total amount indicated above. Signature: Date: Please help us to provide you with speedy customer service; review your application one more time to make sure you have submitted all the required documents and correct payment amount. RETURN YOUR COMPLETE APPLICATION AND PAYMENT TO: Wyoming State Board of Nursing 130 Hobbs Avenue Suite B Cheyenne, WY 82002 Page 3 of 7
COMPLETE THIS APPLICATION ONLY IF YOU ARE APPLYING FOR REINSTATEMENT OF YOUR WYOMING LICENSE OR CERTIFICATION 1) Personal Information: Advanced Practice Registered Nurse Reinstatement Licensed Practical/Vocational Nurse Reinstatement Registered Nurse Reinstatement Certified Nursing Assistant Reinstatement Social Security # Date of Birth Male/Female Last Name First Name Middle Name Maiden Name Mailing Address City State Zip Physical Address City State Zip (If Different from Above) Home Phone Work Phone Cell Phone E-mail Address 2) I meet continued competency requirements by ONE of the following: I have a current national certification as an APRN in my recognized role and population focus area. APRN recognized in the State prior to July 1, 2005 who has maintained continuous licensure, but is not nationally certified: I completed 60 hours or more CEUs related to my APRN recognized role & population focus area; I completed 400 hours as a APRN in the last 2 years; I have prescriptive authority and completed 15 hours of coursework in pharmacology and clinical management of drug therapy in the last 2 years. I worked a minimum of 400 hours as a RN/LPN/LVN in the last 2 years. I worked a minimum of 200 hours as a RN/LPN/LVN in the last 2 years and 15 hours of education that provides learning activities related to nursing practice. I completed 30 hours of RN/LPN/LVN education in the last 2 years related to nursing practice (submit: official certificates or transcripts) RN/LPN/LVN who has not practiced nursing in the last 5 years: I completed a RN/LPN/LVN refresher course or equivalent (submit: official certificates/transcripts); I successfully completed a nursing education program conferring a degree beyond my basic nursing Education; I obtained certification by a nationally recognized professional accrediting agency in a specialty area of nursing that is accepted by the Board (submit verification of national certification). Successfully pass NCLEX. I worked a minimum of 400 hours in the CNA role in the last 2 years; I worked a minimum of 200 hours in the CNA role and 15 hours of education that provides learning activities related to CNA practice in the last 2 years. I completed 30 hours of education that provides learning activities related to CNA practice in the last 2 years. Page 4 of 7
3) Nursing Employment: (for the past 5 years) Begin WITH CURRENT OR MOST RECENT EMPLOYMENT; If employed as a traveling nurse, indicate the individual agency from which you have or are accepting assignments/employment. DO NOT list individual travel assignments. 1. BEGINNING DATE END DATE HOURS PER WEEK EMPLOYER NAME PHONE # ADDRESS CITY STATE ZIP POSITION SUPERVISOR 2. BEGINNING DATE END DATE HOURS PER WEEK EMPLOYER NAME PHONE # ADDRESS CITY STATE ZIP POSITION SUPERVISOR 3. BEGINNING DATE END DATE HOURS PER WEEK EMPLOYER NAME PHONE # ADDRESS CITY STATE ZIP POSITION SUPERVISOR IF YOU NEED MORE ROOM TO COMPLETE YOUR FIVE YEAR EMPLOYMENT HISTORY, PLEASE ATTACH A SEPARATE SHEET Are you currently employed in nursing: If you are currently employed in nursing, check all that apply: No Full time Part time Retired Volunteer Acute Care (Hospital) Assisted Living Case/Disease Management Doctor s Office Home Health Long Term Care (Nursing Home) Nursing Education Private Clinic Public Clinic Public Health School Nurse State Facility Student Telephonic Traveling Agency Unemployed Utilization Review Other: Page 5 of 7
4) History Information: SINCE the surrender, revocation or suspension of your license or certificate, or the issuance of your conditional license or certificate, have you had any of the following? APPLICANT MUST: Answer each question with absolute and complete truthfulness. If you are in doubt about whether or not to report, you should report it; Submit the required documentation for any YES answer. The application is INCOMPLETE until all required documentation is received. 1. Has any DISCIPLINARY ACTION been taken or is pending (i.e. open investigation) against your professional license, certificate, or permit from a licensing authority? No Yes If YES, provide: Personal Statement Documentation of disciplinary action 2. Have you been DENIED a professional license, certificate, or permit? No Yes If YES, provide: Personal Statement Documentation of disciplinary action 3. Have you had a professional license, certificate, or permit REVOKED or SUSPENDED? No Yes If YES, provide: Personal Statement Documentation of disciplinary action 4. Have you VOLUNTARILY SURRENDERED or RELINQUISHED any professional license, certification, or permit? No Yes If Yes, provide: Personal Statement Documentation of disciplinary action 5. Have you been INVESTIGATED or CHARGED WITH ABUSE, NEGLECT OR MISAPPROPRIATION OF PROPERTY by the Department of Family Services (DFS) or Law Enforcement? No Yes If Yes, provide: Personal Statement Documentation of disciplinary action 6. Have you been diagnosed with or treated for any physical or mental condition that significantly disrupts your motor function, cognition, or behavior and may impair your ability to perform nursing services or duties competently? No Yes If Yes, provide: Personal Statement Statement from your provider 7. Have you abused, excessively used, received any treatment for the use of: prescription medication, alcohol, or other any other controlled or illicit substance having similar effects or have you tested positive for a controlled substance for which you did not have a valid prescription? No Yes If Yes, provide: Personal Statement Statement from your provider 8. Have you been terminated or permitted to resign in lieu of termination from a nursing or other health care position because of your use of alcohol, any controlled substance, habit-forming drug, prescription medication, or drugs having similar effects? No Yes If Yes, provide: Personal Statement Statement from your provider 9. Have you been arrested, convicted, pled guilty to, pled nolo contendere to, received a deferment, or have charges pending against you for any crime, including felonies, misdemeanors, municipal ordinances, and/or any military code of justice violations, including driving under the influence of any intoxicating substance? Do not include non-moving traffic violations or moving violations which did not involve alcohol or substance impairment. No Yes If YES, provide: Personal Statement Court Documents (i.e., Information Sheet or Ticket; Judgment and Sentencing; Proof of compliance with the Court Order). SIGNATURE REQUIRED: I certify under penalty of perjury and subject to the provisions of W.S. 6-5-303 and its penalties, that I have not knowingly submitted false or misleading information to the Wyoming State Board of Nursing on any application for licensure or temporary permit. I understand the WSBN reserves the right to verify any information in this application. Applicant s Signature: Date: Please help us to provide you with speedy customer service. Review your application one more time to make sure you are submitting all required documents and correct payment amount. Thank you for applying for a Reinstatement. Page 6 of 7
General Information: Every application is reviewed on an individual basis. The Disciplinary Committee (DC) performs the investigation & assembles materials/information to send to Board. Members of the Board review all materials and make the decision. Fingerprints / Criminal Background Check reveal charges in all states, regardless of your age at the time of the offense, as well as charges you may have been told were dismissed or expunged. The Board will consider the following: Passage of time; Repeated, habitual behaviors; Felony versus misdemeanor (although the nature of the crime is a primary consideration); Compliance with the court orders (probation, payment of fines, completion of required courses, evaluations, etc.); Results/recommendations of existing or requested evaluations (e.g., psychological, psychiatric, substance abuse evaluations, anger management, competency evaluations, etc.); and How the behavior relates to nursing practice and public safety. It takes significantly longer to process your application if you fail to disclose and the issue is revealed through your criminal background check. Court Documents: WSBN requires court documents from the beginning of the arrest to the final disposition of your case, even if the charge(s) was pled down to a lesser charge, deferred, dismissed, etc. Failing to provide complete documentation may delay processing. WSBN requires the following court documents: Charging document or Information Sheet; Judgment and Sentencing; and Documentation of compliance with the court orders. Personal Statement (a SIGNED statement in your own words): A good personal statement includes: o The month and year of the incident; o Full description of the incident; o Legal/court action taken against you, if any; o Treatment & outcome, if applicable (i.e., mental health, substance abuse, etc.) o What you have learned and how you have changed. Specifically, what changes you made in your behavior and decision-making, as a result of the incident; o How you will assure the Board this type of behavior will not happen again o Signature and Date Please visit the discipline tab on our website at: http://nursing.state.wy.us for an example of a personal statement. Page 7 of 7